FORM W-8

EX-99.A.1.X 11 dex99a1x.htm FORM W-8 FORM W-8

Form W-8ECI

(Rev. February 2006)

Department of the Treasury

Internal Revenue Service

Certificate of Foreign Person’s Claim for Exemption From

Withholding on Income Effectively Connected With the

Conduct of a Trade or Business in the United States

Ø Section references are to the Internal Revenue Code. Ø See separate instructions.

Ø Give this form to the withholding agent or payer. Do not send to the IRS.

OMB No. 1545-1621

Note: Persons submitting this form must file an annual U.S. income tax return to report income claimed to be effectively connected with a U.S. trade or business (see instructions).


Do not use this form for:		Instead, use Form:

• A beneficial owner solely claiming foreign status or treaty benefits		W-8BEN
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b)		W-8EXP
Note: These entities should use Form W-8ECI if they received effectively connected income (e.g., income from commercial activities).
• A foreign partnership or a foreign trust (unless claiming an exemption from U.S. withholding on income effectively connected with the conduct of a trade or business in the United States)		W-8BEN or W-8IMY
• A person acting as an intermediary		W-8IMY
Note: See instructions for additional exceptions.

Part I Identification of Beneficial Owner (See instructions.)


1	Name of individual or organization that is the beneficial owner		2 Country of incorporation or organization

3	Type of entity (check the appropriate box): ¨ Individual		¨ Corporation	¨ Disregarded entity
	¨ Partnership	¨ Simple trust or grantor trust	¨ Complex trust	¨ Estate
	¨ Government	¨ International organization	¨ Central bank of issue	¨ Tax-exempt organization
	¨ Private foundation

4	Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box.
	City or town, state or province. Include postal code where appropriate.			Country (do not abbreviate)

5	Business address in the United States (street, apt. or suite no., or rural route). Do not use a P.O. box.
	City or town, state, and ZIP code

6	U.S. taxpayer identification number (required—see instructions)		7 Foreign tax identifying number, if any (optional)
		¨ SSN or ITIN ¨ EIN

8	Reference number(s) (see instructions)

9	Specify each item of income that is, or is expected to be, received from the payer that is effectively connected with the conduct of a trade or business in the United States

Part II Certification


Sign Here		Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:
		• I am the beneficial owner (or I am authorized to sign for the beneficial owner) of all the income to which this form relates, • The amounts for which this certification is provided are effectively connected with the conduct of a trade or business in the United States and are includible in my gross income (or the beneficial owner’s gross income) for the taxable year, and • The beneficial owner is not a U.S. person. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.
		______________________________________________________________________ ____________________ ___________________
		Signature of beneficial owner (or individual authorized to sign for the beneficial owner) Date (MM-DD-YYYY) Capacity in which acting

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25045D Form W-8ECI (Rev. 2-2006)

Form W-8BEN

(Rev. February 2006)

Department of the Treasury Internal Revenue Service

Certificate of Foreign Status of Beneficial Owner

for United States Tax Withholding

Ø Section references are to the Internal Revenue Code. Ø See separate instructions.

Ø Give this form to the withholding agent or payer. Do not send to the IRS.

OMB No. 1545-1621


Do not use this form for:		Instead, use Form:
• A U.S. citizen or other U.S. person, including a resident alien individual		W-9
• A person claiming an exemption from U.S. withholding on income effectively connected with the conduct of a trade or business in the United States		W-8ECI
• A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions)		W-8ECI or W-8IMY
• A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions)		W-8ECI or W-8EXP
Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding.
• A person acting as an intermediary		W-8IMY
Note: See instructions for additional exceptions.

Part I Identification of Beneficial Owner (See instructions.)

Name of individual or organization that is the beneficial owner

2 Country of incorporation or organization

Type of beneficial owner

¨ Individual

¨ Corporation

¨ Disregarded entity

¨ Partnership

¨ Simple trust

¨ Grantor trust

¨ Complex trust

¨ Estate

¨ Government

¨ International organization

¨ Central bank of issue

¨ Tax-exempt organization

¨ Private foundation

Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.

City or town, state or province. Include postal code where appropriate.

Country (do not abbreviate)

Mailing address (if different from above)

City or town, state or province. Include postal code where appropriate.

Country (do not abbreviate)

U.S. taxpayer identification number, if required (see instructions)

7 Foreign tax identifying number, if any (optional)

¨ SSN or ITIN ¨ EIN

Reference number(s) (see instructions)

Part II Claim of Tax Treaty Benefits (if applicable)

I certify that (check all that apply):

¨ The beneficial owner is a resident of __________ within the meaning of the income tax treaty between the United States and that country.

¨ If required, the U.S. taxpayer identification number is stated on line 6 (see instructions).

¨ The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions).

¨ The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions).

¨ The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500,000.

Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article ________ of the treaty identified on line 9a above to claim a ________ % rate of withholding on (specify type of income): ____________________________________

Explain the reasons the beneficial owner meets the terms of the treaty article: ________________________________________________________

Part III Notional Principal Contracts

¨ I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required.

Part IV Certification

Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:

• I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates,

• The beneficial owner is not a U.S. person,

• The income to which this form relates is not effectively connected with the conduct of a trade or business in the United States or is effectively connected but is not subject to tax under an income tax treaty, and

• For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner.


Sign Here Ø		_______________________________________________________________________ ___________________ ____________________
		Signature of beneficial owner (or individual authorized to sign for the beneficial owner) Date (MM-DD-YYYY) Capacity in which acting

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 2-2006)